Comprehensive Sexuality Education
I. Definition of the Prevention Area
Young people in many countries have unprotected sexual intercourse with one or more partners, potentially exposing themselves to HIV, other sexually transmitted infections (STIs), or unintentional pregnancy. Comprehensive sexuality education (CSE) programs work to delay initiation of sex, reduce the number of sexual partners, and increase the use of condoms and other forms of contraception. Some programs also seek to increase testing and treatment for HIV and other STIs. They can be implemented both in schools and in other community settings.
II. Epidemiological Justification for the Prevention Area
The global HIV epidemic cannot be reversed without sustained success in reducing new infections. The proportion of new HIV infections attributed to young people varies greatly across countries and by type of epidemic. A recent United Nations Children's Fund report estimates that young people aged 15 to 24 accounted for 41 percent of all new HIV infections in adults in 2009. This represents an estimated 5 million young people. In sub-Saharan Africa, nearly 3.3 million youth are living with HIV. Globally, young women make up more than 60 percent of all young people living with HIV; in sub-Saharan Africa, their share jumps to 72 percent.
Young people can reduce their chances of contracting HIV if they reduce their sexual risk by, for example, delaying sex, reducing the number of partners they have, avoiding sex with older partners and with people having concurrent partners, increasing condom use, and, for uncircumcised men, undergoing voluntary medical circumcision. There is strong evidence that CSE programs with certain core programmatic components can reduce sexual risk by changing some of these behaviors. When these programs are implemented in schools, they can reach very large numbers of young people before and after they begin having sex. They can also reach out-of-school youth in clinics, other youth-serving organizations, and communities more generally.
III. Core Programmatic Components
Some CSE programs have reduced sexual risk-taking, while others have not. Effective programs incorporate 24 core characteristics in their development and implementation. For example, they involve experts in behavior change theory and research, involve young people in the design of the program, use a clear logic model, focus on specific behavioral goals and specific cognitive factors that affect those behaviors (e.g., knowledge, perception of risk, values, attitudes, peer norms, skills, intentions), employ multiple participatory activities that address those cognitive factors, give clear messages about behavior, implement at least 12 sessions (if in schools), and provide training to educators.
IV. Current Status of Implementation Experience
Close to 100 studies have examined the impact of CSE programs around the world. These studies include strong quasi-experimental or experimental designs. Their results support several conclusions about the impact of CSE programs:
- A third or more of these programs delayed sex, reduced frequency of sex, reduced number of partners, increased condom use, increased overall contraceptive use, or reduced unprotected sex.
- Almost two-thirds had a desired impact on one or more of these sexual behaviors.
- None increased any measure of sexual activity.
- Virtually all programs that incorporated the core components had significant desired effects on behavior.
- Their positive impact on behavior is modest, but programmatically meaningful.
If implemented on a large scale, effective CSE programs represent a cost-effective method of changing behavior and thus can serve as an important component within comprehensive initiatives to reduce HIV, other STIs, and unintended pregnancy.
This overview of the HIV epidemic among young people is one of the most up-to-date reports on HIV among this age group. It describes the epidemiology of the HIV epidemic among young people at a global and regional level, followed by detailed chapters focusing on very young adolescents, older adolescents and young adults, as well as adolescents and young people living with HIV, with case studies, maps, and easy-to-use data. There are statistics on demographic, epidemiological, and education level indicators among this population; a chapter on their knowledge, sexual behavior, access, and testing patterns; and HIV indicators for young people at higher risk. It advocates a continuum of prevention to protect young people from HIV and details other opportunities for action that arise from this public health crisis.
This systematic review of 63 studies on the impact of sex and sexually transmitted infection education on young people's sexual behavior found that most of the interventions increase young people's knowledge. Approximately a third delayed sexual debut, frequency of sexual intercourse, and number of partners, while approximately 40 percent of the interventions increased the use of condoms and other contraceptives. The reduction in risky sexual practices was not dramatic, but was sufficient to reduce rates of pregnancy and sexually transmitted infections, the author notes. Although the studies covered a wide geographical area, their findings may not have worldwide applicability, and none of the studies looked at same-sex sexual behavior or population-level changes due to large-scale roll-out.
In this cluster randomized controlled trial of 86 community-based organizations serving African American adolescents, 1,700 adolescents either received a health promotion education intervention from an organization assigned to this group or from an organization assigned to deliver an intervention targeting HIV and sexually transmitted infections (STIs) risk reduction. The participants were followed up at three intervals for 12 months. Those in the HIV/STI intervention group were more likely to report consistently using condoms than their counterparts who did not receive the intervention. The study was the first of its kind to prove that community-based organizations are an efficient channel through which to implement HIV/STI risk reduction interventions. The study also found that training costs for facilitators were not prohibitively high.
This review examines which factors have the greatest bearing on adolescent health in a developing country setting, both in terms of risk and protection. Sixty-one papers were analyzed, and the review looked at factors associated with premarital sex, condom use, and pregnancy. It revealed that factors outside the individual, such as peer, partner, family, and school level, had little impact on sexual risk behaviors, while the strongest associations were related to adolescents themselves, such as gender, education, and non-sexual risk behaviors. The authors note the lack of rigorous research in this area and call for a broader research base. However, the review already identifies several important factors, for example, communication with partners, concurrently targeting different risk factors such as substance abuse and sexual behavior, and harnessing the powerful role of parents in influencing their adolescent children.
This is a systematic review of 23 studies of HIV education programs for young people in sub-Saharan Africa conducted from 2005 to 2008. The review constitutes an update of the first Steady, Ready, Go! review and uses its framework of evaluation of school-based interventions, health services, and geographically defined communities, with an additional section on interventions with biological outcomes. The authors describe school-based interventions as largely successful in terms of educating young people about sexual risk behaviors, but not enough to effect actual risk reduction. Interventions aimed at HIV prevention via improved access to health services can only be successful if they are acceptable to and used by young people. Interventions in geographically defined communities are particularly problematic to evaluate, the authors found. They conclude that a range of tools is needed and that a one-size-fits-all approach to young people and HIV prevention will not be effective.
This review summarizes research into sexual risk behavior and its consequences among young people in the United States. It is the largest, most in-depth systematic review of multiple kinds of programs. There is information about the prevalence of risky sexual behavior, and the resultant rates of teen pregnancy and sexually transmitted infections (STIs). There are detailed chapters on the case for prevention; factors affecting teenagers' sexual behavior; a description of the review methodology; and the findings, divided into curriculum-based sex and HIV/STI prevention interventions and other types of programs. The report concludes with a chapter on application of research to communities, highlighting those that have strong evidence of efficacy in reducing teen pregnancy and rates of STIs.
This review focuses on evidence from high-income countries measuring biological, behavioral, cognitive, attitudinal, or other outcomes related to HIV risk reduction. The 39 studies included are only from North America due to a lack of available literature from other countries. Interventions promoted sexual abstinence, condom use, and partner reduction for HIV prevention, with abstinence the most effective choice. Most studies measured behavioral rather than biological outcomes. Twenty-three studies found a significant protective effect on sexual risk behavior, including incidence and frequency of unprotected sex, number of partners, condom use, and sexual initiation. No adverse effects on behavioral outcomes were found. Because of differences between studies, the authors could not aggregate most data. They recommend the HIV research community define consistent outcome measures that reflect HIV risk. This would enable biological data to be more easily pooled and overcome the statistical limitations that come with low incidence rates and small sample sizes.
This review presents in a table format more than 500 risk and protective factors that can affect the rate of teen pregnancy and sexually transmitted infections (STIs), and assesses the extent to which interventions aimed at reducing teen pregnancy and STI rates can change them. The findings are based on over 400 studies. The review gives each intervention a star rating (one star denoting a factor that is the most difficult to change directly by pregnancy and STI programs, up to three stars denoting those factors most amenable to change by pregnancy and STI programs). The factors fall into four broad categories: individual biological factors; disadvantage and dysfunction in the teenager's lives and environments; the sexual values and modeled behavior of teenagers as well as their parents, peers, and partners; and connections that discourage early sexual activity and teen pregnancy, such as attachment to influential adults in schools and via religious organizations.
This systematic review of 22 studies from developing countries worldwide assessed the efficacy of interventions to reduce a total of 55 sexual risk behaviors, such as sexual debut, frequency of sexual intercourse, condom use, and sexually transmitted infections. The studies included those that used both curriculum- and non-curriculum-based interventions; incorporated characteristics that were known to be effective HIV prevention interventions or did not, and were led by teachers, other adults or peers. The review found that reported risky sexual practices were lower after most school-based sex and HIV education interventions. The authors recommend wider implementation of curriculum-based programs incorporating interventions that are already known to be effective, and caution that more research is needed to evaluate peer-led and non-curriculum-based interventions.
This randomized controlled trial tested the effectiveness of a HIV prevention intervention in a cohort of 550 Latino adolescents. The participants underwent six 50-minute modules delivered in English or Spanish by adult facilitators either on HIV or health promotion. They were then followed up for a year and self-reported their sexual behavior. Sexual intercourse, multiple partners, and unprotected sex were reported less by the adolescents in the HIV group. At follow-up, adolescents in the HIV group who were sexually inexperienced at baseline reported less incidences of unprotected sex in the previous three months compared to the adolescents in the health promotion group. The study was the first to demonstrate that such an intervention can be effective among Spanish-speaking young people, and the activities may have applicability in Latin American and other Spanish-speaking countries, although more research is needed to test the generalizability of the findings, the authors note.
This randomized controlled trial compared three different school-based HIV interventions. They were teacher training in the government's HIV education curriculum, encouraging debate and essay writing among students in condom use for HIV prevention, and making education less expensive. Teenage childbearing, associated with unprotected sex, was the primary outcome of the study, while the secondary outcome was HIV knowledge, attitudes, and behavior. Teacher education did not reduce teen pregnancies, but it increased the number of teen pregnancies within marriage. The student essay writing and debates intervention was associated with higher self-reported condom use at the same level of sexual activity. Lower education costs were associated with lower dropout rates as well as fewer teen pregnancies. However, to determine whether self-reported condom use after the school-based intervention is associated with lower incidence of HIV, biomarker tests would need to be used, the authors note.
This randomized control trial tested the Relative Risks Information Campaign, which was implemented among 2,500 Grade 8 students in 71 schools in Kenya, comparing them with the cohort a year ahead or below as the control group. The information campaign informed the teenagers of the higher prevalence of HIV among adult men and their partners relative to teenage boys. The intervention led to a 65 percent reduction in teenage pregnancies to adult male partners, suggestive of a significant reduction in cross-generational unprotected sex. It also led to an increase in self-reported condom use among teenage couples. This suggests a substitution effect, but it did not lead to an increase in pregnancies where both partners were teenagers. The author argues that educating teens about HIV risks without specifying the risk distribution may be missing out on an important opportunity for risk reduction.
This training manual is one of only four rigorously evaluated curricula in Africa that demonstrated impact on sexual behavior. Program A is for trainers, teachers, and parents involved in the implementation of the AIDS Education Syllabus. It provides a plethora of learning resources, including detailed trainers' notes, timed session outlines, and many handouts. Course B uses the core courses from course A. In addition, it enables participants to evaluate their action plans for implementation of the syllabus and ascertain any weaknesses and gaps. The course equips participants to provide factual information to young people to promote safe sexual behavior. The training should also enable participants to strengthen their inter-sectoral networking and set up support activities.
This cluster randomized controlled trial of 2,700 men and women in 70 villages in the Eastern Cape province of South Africa tested the Stepping Stones program. It comprised 50 hours of participatory learning aimed at improving sexual health. Villages in the control group received a three-hour intervention of HIV and safer sex education instead. The primary outcome was incidence of HIV at 12 and 24 months, with secondary outcomes of herpes simplex type 2 (HSV-2) infection, unwanted pregnancy, depression, substance misuse, and sexual habits such as the number of partners and history of transactional sex. The intervention lowered rates of HSV-2 infection, but it did not have an impact on incidence of HIV. It did not have an effect on female behavior but reduced incidence of intimate partner violence perpetrated by male participants. Although the intervention failed to directly reduce HIV rates, it did have an impact on two risk factors for HIV, namely HSV-2 infection and intimate partner violence.
A group of international youth HIV and reproductive health researchers, program implementers, curriculum development experts, educators, and others met to discuss the Kirby 2005 review of characteristics of effective curricula. This expert consultation provided the crucial perspective of those implementing curriculum-based health education programs in developing countries. Based on their program implementation experiences, each of the characteristics Kirby identified as a hallmark of successful programs was carefully reviewed and discussed. This resulted in the group developing 24 standards of high-quality health program features that can assess the quality of a curriculum--existing or proposed--and its implementation. The standards are divided into three sections: (1) curriculum development and adaptation, (2) curriculum content and approach, and (3) curriculum implementation. The implementation section has multiple examples and lessons learned from implementation experiences worldwide.
This report is a systematic review of 158 studies on adolescent sexual behavior risk and protective factors in developing country settings. The findings are presented as individual and also as cross-cutting risk factors. Important themes emerged; for example, only 1 percent of the more than 11,000 papers published on this topic met the review's inclusion criteria, few studies consider contextual factors, and factors specific to non-westernized regions have been under-researched. There is also little evidence on the impact of coercive sexual practices despite the fact that adolescents are primary targets. Moreover, the most commonly analyzed factors were sociodemographic, but these are the least amenable to interventions. The review is subject to a number of limitations, such as clustering of research in a few countries and a paucity of data from North Africa, Eastern Europe, Central Asia, and the Caribbean. Because most of the studies reviewed are cross-sectional, causality cannot be determined.
This systematic review of 83 program evaluations had two main aims: to ascertain the effects of curriculum-based sex and HIV education on sexual risk behaviors, and to discover the shared characteristics of those programs that were effective. The studies covered composite risk-taking measures as well as individual risk factors such as timing of sexual debut, frequency of sex, number of sexual partners, and use of condoms and other contraceptives. The programs had an overall positive impact on one or more sexual risk behaviors, and outcomes were similar in developed and developing country settings. Factors that successful interventions had in common include curricula developed by diverse teams working toward clearly defined goals, a safe environment for young people that gave them ownership of the information, and implementation by trained educators with minimal support from authorities. The report offers recommendations, both for program designers and for further research.
This report brings together 10 interventions in seven countries that had demonstrable success in reducing sexual risk factors such as initiation of sex, number of sexual partners, and contraceptive use. There are tables comparing the design and impact of the 10 interventions, and a chapter for each describing them in detail from program components and evaluation methodology to outcomes. What the programs have in common is that they treat young people in a holistic manner, consider sexual development to be a normal part of adolescence, and involve key stakeholders. They are described by the authors as culturally appropriate, thoughtful, and realistic. They provide comprehensive information covering both contraception and abstinence, and many of them incorporate youth health or health care referral services.
This detailed report presents an evaluation of the Primary School Action for Better Health project, implemented in Nyanza and Rift Valley in Kenya. The project had numerous positive outcomes. First, it shifted pupils' primary reported source of information about HIV away from the mass media and toward teachers and school texts, although this did not undermine female relatives as the preferred source of information for both sexes. Second, the project corrected misinformation among pupils and improved their critical thinking about HIV. Abstinence was presented as the only fully effective means of HIV prevention, and the project incorporated strategies to encourage it. However, information about condom use was often negative and at times even factually incorrect, reflecting teachers' ambivalence about discussing condoms with pupils. Overall though, teachers responded well to the project, and HIV education is more prominent on the school curriculum as a result of the project, the study found.
This randomized controlled trial of 20 high schools in California and Texas comprising a cohort of over 3,800 students tracked their sexual risk and protective behaviors after the implementation of Safer Choices, an educational program aimed at behavior change to prevent HIV, other sexually transmitted infections, and teen pregnancy. The most noticeable outcome was that condom use improved after the intervention. It also improved some psychosocial variables predominantly related to condom use. The effects were sustained over 31 months of follow-up. However, age at sexual debut remained the same, as did frequency of intercourse and number of sexual partners. The study supports further implementation of theory-driven, school-based, multicomponent programs to reduce HIV-related sexual risk behaviors, the authors found. Safer Choices was well received by both students and staff, and even after the study ended, most of the schools continued to use the curriculum.
The Stay Healthy HIV prevention curriculum, which has been pilot tested in Namibia, addresses gender as a way to reduce sexual risk behavior. The report describes gender-specific norms that have an impact in sexual risk behaviors and the gender transformative approach to tackling them. The curriculum comprises 18 sessions and three homework assignments. The objectives of the curriculum are to enable young people to understand how unprotected sex could interfere with their future life goals; understand human sexuality across different life stages; have a sound understanding of HIV transmission, prevention, and consequences; and understand their own HIV risk. There are appendices describing the theory of change logic model that underpins the Stay Healthy intervention and a sample consent form for parents and guardians.
To respond to the intractable HIV epidemic among youth, the United Nations Educational, Scientific and Cultural Organization and partners undertook a systematic review of sexuality education programs. Their conclusions were informed by studies that evaluated 85 worldwide youth sexuality education programs through 2009. Volume 1 presents the evidence for developing comprehensive sexuality education programs, the characteristics of effective programs, and recommendations based on good practices in schools. It is intended to help people develop and implement comprehensive sexuality education in schools.
To respond to the intractable HIV epidemic among youth, the United Nations Educational, Scientific and Cultural Organization and partners undertook a systematic review of sexuality education programs. Their conclusions were informed by studies that evaluated 85 worldwide youth sexuality education programs through 2009. Volume 2 presents the basic minimum package for comprehensive sexuality education. Learning objectives include six key concepts broken down by appropriate messages for various age groups, and resource lists include comprehensive sexuality education curricula, teacher training manuals, and curriculum guides selected by an expert technical group.
This comprehensive package of resources takes as its starting point gender inequality as a key driver of the HIV pandemic. It is a practical curriculum that focuses on gender, sexuality, and HIV, and has seven key features: it is evidence based, comprehensive, takes a human rights-based approach, is gender sensitive, promotes critical thinking, encourages engagement, and is culturally sensitive. It comprises of guidelines and activities. The guidelines are for curriculum developers and educators as well as health and education policymakers and school administrators. There is also a book of 54 activities for young people to foster critical thinking skills. It is available in English, Spanish, and French.
This tool is one of the few materials of its kind available in Spanish. It uses an organized set of questions to enable users of curriculum-based programs to assess how much a curriculum incorporates elements that are known to be effective. This in turn enables them to select HIV, other sexually transmitted infection, and pregnancy-prevention programs that are the most suitable for the community they serve. It can also be used to guide the development of a new curriculum and to implement an existing curriculum more effectively. There are three sections describing the profile of effective curricula, and a section each summarizing the characteristics in table form, providing useful resources and a glossary.
This practical tool enables users to deploy intervention mapping to plan school-based sexual and reproductive health and rights education programs. In this way, they can determine to what extent the curriculum incorporates interventions that are based on evidence of efficacy in changing behavior. The primary target users are project workers from government and nongovernment organizations working on sexual and reproductive health and rights projects in developing countries, although it is also useful for researchers and curriculum consultants. There is a detailed description of intervention mapping and a step-by-step guide to using it to evaluate curricula.
This tool uses an organized set of questions to enable users of curriculum-based programs to assess the extent to which a curriculum incorporates elements that are known to be effective. This in turn enables them to select HIV, other sexually transmitted infection, and pregnancy-prevention programs that are the most suitable for the community they serve. It can also be used to guide the development of a new curriculum and to implement an existing curriculum more effectively. There are three sections describing the profile of effective curricula, and a section each summarizing the characteristics in table form, providing useful resources and a glossary.
This randomized controlled trial evaluated a HIV prevention curriculum delivered to 500 sexually experienced African American teenage girls. The curriculum comprised four group sessions of four hours each. Intervention group sessions covered HIV knowledge and condom use skills, as well as ethnic and gender pride, healthy relationships, and communication. The control group received sessions on exercise and nutrition. Six and twelve months after the intervention, the participants were interviewed, self-completed a questionnaire, provided samples to test for sexually transmitted infections, and also showed their condom use skills. Among the intervention group, condom use was more consistent. The girls in this group also demonstrated better condom application skills, fewer new partners, and fewer acts of unprotected sex. Chlamydia infections and self-reported pregnancy outcomes were also positive. It was the first trial to demonstrate that it is possible to effect behavior change among sexually experienced African American adolescent girls, the authors note.
This teachers' guide comprises 11 sessions of 40 minutes based on a variety of teaching methods including group work, competition, quizzes, games, drama, simulations, and stories. The sessions cover how HIV causes AIDS; the transmission modes of sexually transmitted infections and their relationship to HIV; reproductive organs, pregnancy, and menstruation; condoms; and interpersonal topics such as respecting other people's decisions and dealing with temptation. It was designed for rural schools in Tanzania and was rigorously tested by a randomized controlled trial, showing that it improved multiple sexual behaviors among young people.
Children and AIDS: Fifth Stocktaking Report
United Nations Children's Fund, Joint United Nations Programme on HIV/AIDS, World Health Organization, United Nations Population Fund, & United Nations Educational, Scientific and Cultural Organization. (2010).
This report covers the whole span of HIV and childhood from prevention of mother-to-child transmission, pediatric care and treatment, and HIV prevention among adolescents and young people, as well as protection, care, and support for children affected by HIV and AIDS. The chapter on adolescents describes the progress made on prevention of new HIV infections, discusses the barriers to HIV prevention among this age group, and what factors have made prevention strategies successful.
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UNAIDS Report on the Global AIDS Epidemic 2010
Joint United Nations Programme on HIV/AIDS. (2010).
This report provides an update of the state of the HIV epidemic, including data and commentary on HIV and young people. It has chapters on HIV prevention and treatment, as well as human rights and gender, and investment in HIV. There are country-specific progress indicators and estimates of HIV and AIDS for 2001 and 2009. It is rich in tables, maps, and illustrations, making it easy to read and use.
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U.S. Centers for Disease Control and Prevention. (2009).
This webpage on school connectedness, defined as students' belief that their teachers and peers care about their learning and about them as individuals, has numerous useful links. There is a downloadable strategy guide (PDF, 1.7 MB) on fostering school connectedness, fact sheets, and a staff development program. The facilitator's guide (PDF, 1.1 MB) for the staff program is also available for download, and there are two PowerPoint presentations, one giving an overview of school connectedness and another on action planning for school connectedness.
What Works Best in Sex/HIV Education?
Center for AIDS Prevention Studies, University of California, San Francisco. (2006).
This two-page document lays out the case for sex education, argues that it works, and that effective programs are replicable. It highlights studies of curricula found to bring about significant behavior change and describes the main features of effective curricula. It calls on policymakers to fund and support the implementation of sex and HIV education programs, particularly among subgroups known to be at higher risk of HIV, sexually transmitted infections, and unplanned pregnancy.
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